Perinatal

Question 1

When is the perinatal period

Answer 1

Pregnany + up to 1 year following birth

Question 2

Baby blues

Answer 2

Distressing but normal
Experiences by 50-75% of mothers a few days after birth
Onset: 2-5 days post birth; duration: few days

Sx: pt feels weepy, irritable, muddles, mood lability/feels all over the place (lows and highs), maybe trouble sleeping

Probably due to hormonal disruption and sleep deprivation

Treatment: explanation and reassurance, occasionally may progress to postnatal depression

Question 3

Postnatal depression onset, duration and risk factors

Answer 3

Onset: 4-12 weeks; duration: weeks-years

RFs

• Personal/F Hx PND or depression
• Younger maternal age
• Recent life events
• Marital discord
• Poor social support

Question 4

Clinical features of postnatal depression

Answer 4

Similar to normal depression:

• Core: low mood, anhedonia, anergia (must have 2)
• Physical: changed in sleep, appetite, libido; (low energy, concentration, sleep are normal in new mothers)
• Cognitive: hopeless, helpless, worthless (tend to relate to baby/failure as mother)

Fatigue, irritability, anxiety
Recurrent intrusive thoughts about harming the baby can occur as distressing obsessions

Question 5

Investigations into postnatal depression

Answer 5

Screen at booking visit - bothered by feeling down, depressed, hopeless or bothered by having little interest or pleasure in doing things during past month?

Also consider asking about anxiety using 2-item -GAD scale (GAD-2): bothered by feeling nervous, anxious, on edge, not being able to stop or control worrying over last 2 weeks?

Question 6

Management of postnatal depression

Answer 6

Expedited referral to IAPT (improving access to psychological therapies)

NICE:
Subthreshold/mild-moderate Sx:
- Consider referral for facilitated self-help
- If Hx of sever depression: consider TCA, SSRI, SNRI
Moderate-severe depression:
- Consider referral for high-intensity psychological intervention (aim to assess in <2wks)
- Consider medication: TCA, SSRI, SNRI - 1st line in breastfeeding women: paroxetine and sertraline (monitor baby for sedation, poor feeding and behavioural effects)
- If using TCAs, imipramine and nortriptyline are preferred; avoid doxepin; monitor baby

Generally same as depression, but with care in breastfeeding mothers

• SSRIs recommended: paroxetine and sertraline
• Low dose amitriptyline i sok
• Lithium avoided if possible, sodium valproate definitely avoided

Consider hosp admission if severe depression with suicidal/infanticidal ideation - mother and baby unit; separation avoided if possible

Early and effective Tx important; can affect baby’s attachment and have lasting effects on development and personality

Question 7

Puerperal psychosis onset and risk factors

Answer 7

Onset: peaks first 4 weeks (risk highest in first few days); duration: weeks - months

RFs:
Personal/F Hx of puerperal psychosis or BPAD
Puerperal infection
Obstetric complications
First time mothers

Question 8

Aetiology of puerperal psychosis

Answer 8

Sudden drop in oestrogen and progesterone following delivery
?Autoimmune (?thyroid autoAb)
Genertic variations in chr 16p13, 8q24, serotonin transport gene
Triggers: social stressors, sleep deprivation, abrupt discontinuation of breastfeeding
?similar links to pre-eclampsia

Question 9

Clinical features of puerperal psychosis

Answer 9

Usually rapid onset
Severely affective psychosis, rapidly/dramatically change/fluctuate, mixed presentations

Often starts with insomnia, restlessness, irritable and perplexity (inability to understand something)
Later, suddenly psychotic symptoms will emerge; tend to follow one of three patterns:
-Delirium
-Affective (life psychotic depression or mania)
-Schizophreniform (like schizophreniu)

Question 10

Investigations for puerperal psychosis

Answer 10

Exclude underlying delirium or substance misuse (intoxication/withdrawal)

Risk assess:
To self: self neglect, disorientation/confusion, bizarre behaviour, suicidal ideation and acts
To others: neglect of infant/other dependants, thought to harm infant, delusional beliefs involving infant
From others: domestic/interpersonal/sexual violence, exploitation

Question 11

Management of puerperal psychosis

Answer 11

Depends on presentation: antipsychotics, antidepressants, lithium

Benzos may be needed for agitation

In severe cases, ECT may be life saving
Admission is usually required, preferably to a mother and baby unit
Most pts recover within 6-12 weeks

Question 12

NICE guidelines on MH problems during and after pregnancy

Answer 12

Biological Tx

• Discuss the risk/benefit differences before starting Tx in pregnant/postnatal woman
• If taken psychotropic medication with known teratogenic risk at any time in first trimester: confirm pregnancy asap; explain that stoping/switching meds may not remove risk of malformations; offer screening for fetal abnormalities and counselling; explain need for additional monitoring and risks to fetus if meds are continued

Choosing a TCA, SSRI, SNRI, factors:
-Woman prev response to drug
-Stage of pregnancy
-What is known about reproductive safety of the drugs
-Risk of discontinuation symptoms in woman and neonatal adaptation syndrome
Do not use valproate in women of child bearing age